OIC: Alarming Rates of Preventable Adverse Events

A startling number of adverse events affect Medicare beneficiaries in hospitals, according to a study from the Department of Health and Human Services' Office of Inspector General. Based on a random sample of 780 beneficiaries discharged during October 2008, the OIG estimates:

* 13.5 percent of beneficiaries experienced adverse events during their hospital stay--prorated to 134,000 beneficiaries experiencing at least one adverse event during that single month;

* Another 13.5 percent experienced other events not labeled as "adverse" that resulted in temporary harm. Many cases were minor, but others were classified as "temporary" only because the patients were in the hospital for a lengthy period for other reasons, which allowed the hospital enough time to address the "temporary harm" before discharge;

* 44 percent of adverse and temporary harm events were "clearly" or "likely" preventable; and

Among other recommendations, the OIG calls on the Centers for Medicare and Medicaid Services and Agency for Healthcare Research and Quality to broaden patient safety efforts to include all types of adverse events. Further, AHRQ should sponsor periodic and ongoing measurement of the incidence of adverse events, and should continue to encourage hospitals to report events to Patient Safety Organizations, which populate a national AHRQ database.

OIG also recommends CMS expand its list of hospital-acquired conditions to include more harmful events, and to hold hospitals accountable for adoption of evidence-based practice guidelines.

The American Hospital Association issued the following statement on the OIG report:

"While hospitals have made great strides in improving care, this report highlights that there is more we can do. Hospitals are already engaged in important projects designed to improve patient care in many of the areas mentioned in the report. We are committed to taking additional needed steps to improve patient care. That is why we support the report's recommendations for further research to improve our understanding of what caused the error and how to prevent it from happening again."

The Office of Inspector General report, "Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries," is available at http://oig.hhs.gov/.